Auto Accident Mechanism Of Injury Form
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1
2Green Lotus Acupuncture LLC
Mary Jean Brinkman L.Ac.
Patient’s Name: ______________________________________ Today’s Date: ____________
Auto Accident Mechanism of Injury Form
Date of Collision: ____________________________ Hour of Accident: __________________ AM / PM
Please describe how the collision happened: ______________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
What was your position in the car? (Circle)
Driver / Front Passenger / Left Rear / Right Rear
If “Driver”, were your hands on the steering wheel?
Both / Left / Right
Did the airbags deploy?
Yes / No
Did you strike another vehicle?
Yes / No
Did another vehicle strike your vehicle?
Yes / No
Angle of Impact:
Front / Back / Left / Right / Other: ____________________________________
If Second Collision – Angle of 2
nd
impact:
Front / Back / Left / Right / Other: _________________
1) In relation to the back of your head, was your headrest set:
Low / Middle / High
2) Were you surprised by the impact?
Yes / No
If “NO”, how did you brace?
With Hands / With Feet
3a) Where was your head facing at the time of impact?
Straight Ahead / Left / Right / Behind
3b) Were you leaning forward at the time of impact?
Yes / No
4) What type and year of vehicle were you in? ____________________________________________
__________________________________________________________________________________
5) What type and year of vehicle struck yours?_____________________________________________
__________________________________________________________________________________
6) Were you wearing a seatbelt?
Yes / No
What type:
Lap Belt / Shoulder Belt / Both
7) Did you feel pain immediately after the accident?
Yes / No
Were you rendered unconscious as a result of the accident?
Yes / No
If “YES”, specify what part of
Did you strike anything in the vehicle at the time of impact?
Yes / No
your body struck what: (i.e. head, chest, chin, shoulder, knee, etc.)
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□
Steering Wheel
Windshield
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□
Dashboard
Roof
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Left Side Door
Right Side Door
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□
Left Window
Right Window
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Other
Did your seat break or bend?
Yes / No
Immediately following the accident, how did you feel? (Circle all that apply)
Dizzy / Dazed / Weak /
Upset / Disoriented / Nervous / Nauseous / Other: _______________________________________
5308 SE Rhone St
Phone: 503-789-7661
1
Portland, OR 97206
Fax: 503-775-2451
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